儿童慢性肺曲霉菌病四例的诊断和治疗

目的 探讨儿童慢性肺曲霉菌病的诊断和治疗。方法 分析4例儿童慢性肺曲霉菌病的表现、诊断和治疗,并复习有关文献。结果 (1)4例均表现为长期或间断发热、咳嗽,病程3月～1年。其中2例合并胸壁脓肿。(2)2例肺部闻及细湿哕音并肝脾肿大,另2例肺部及其他部位检查无异常。(3)2例患儿发病前无基础疾病史,1例患慢性肉芽肿病,1例曾患原发性肺结核。4例患儿IgG、IsA、IgM、IgE,T细胞亚群、总补体和C3、C4、中性粒细胞数量均正常。3例四唑氮蓝试验正常,1例异常。(4)胸部影像学表现：4例在病程中均表现为单侧肺叶实变伴胸膜肥厚。2例病初表现为多发结节影。(5)4例痰液培养均有曲霉菌生长,2例行肺活检,在肺组织中发现曲霉菌菌丝或孢子。2例合并胸壁脓肿者,脓液培养也有曲霉菌生长。(6)4例患儿均联合应用二性霉素B和伊曲康唑治疗,10d～1个月症状控制。结论 对于有长期发热、咳嗽,胸部影像表现为肺叶实变伴胸膜肥厚或为结节性阴影,病情进展缓慢的儿童,应考虑慢性肺曲霉病的可能。确诊依赖于多次痰液培养或肺组织培养或在肺组织中发现曲霉菌生长。一旦确诊,联合应用二性霉素B和伊曲康唑可使病情控制。

Diagnosis and treatment of chronic pulmonary aspergillosis in 4 children

Objective Chronic pulmonary aspergillosis is different from acute pulmonary asp ergillosis in clinical picture, radiogram, diagnostic procedures and prognosis. Four patients with chronic pulmonary aspergillosis had been misdiagnosed as havi ng pneumonia or pulmonary tuberculosis for a long time before admission to the h ospital. The purpose of this report was to summarize the clinical manifestations and laboratory findings for correct diagnosis of chronic pulmonary aspergillosi s. Methods Four patients with chronic pulmonary aspergillosis seen between Octo ber 2002 and October 2004 were retrospectively studied. Their clinical manifesta tions, chest radiographic feature, immune status, diagnostic procedure, therapy and prognosis were reviewed. Results The chief complaints of these patients were chronic cough and fever for 3 to 12 months. Chest wall abscess developed in the late course in case 1 a nd 4. Fine moist rales were heard and hepatosplenomegaly was found in case 1 and 2. No abnormal sign was found in case 3 and 4. Chest radiographic feature: loba r consolidation with adjacent pleural thickening was present in all cases. In ea rly phase, solitary or multiple small nodules were found in 2 cases. Case 1-3 ha d normal IgG, IgM, IgA, IgE, T Cell subsets and NBT test. Case 4 had chronic gra nulomatous disease. Etiologic evidences: culture was positive for Aspergillus (A.) fulmigatus in sputum and in chest wall abscess in case 1 and 4; for A. niger in sputum and spore existing in lung tissue in case 2; for A. fulmigat us in sputum and hypha existing in lung tissue in case 3. All patients were tr eated with combination of amphotericin B and itraconazole. Their symptoms were c ontrolled 10-30 d after treatment. In case 1 the disease relapsed 6 months later and the patient died at last due to giving up treatment by his parents. Case 2 was free of symptom for 12 months and his chest radiographic lesion disappeared completely 6 months later. Treatment of case 4 was given up. Case 3 continued t o receive treatment and observation. Conclusion Chronic pulmonary aspergillosis should be considered in children with long period fever and cough and lobar consolidation associated with adjacent pl eural thickening or with nodular infiltration. The diagnosis of chronic pulmonar y aspergillosis depended on identification of aspergillus from sputum or lung ti ssue. Combined amphotericin B and itraconazole might control the disease.